Lyme Disease, Anaplasmosis, and Babesiosis, Atlantic Canada

In July 2021, a PCR-confirmed case of locally acquired Babesia microti infection was reported in Atlantic Canada. Clinical features were consistent with babesiosis and resolved after treatment. In a region where Lyme disease and anaplasmosis are endemic, the occurrence of babesiosis emphasizes the need to enhance surveillance of tickborne infections.

B abesiosis is an emerging infectious disease caused by a zoonotic hemoprotozoan parasite of the genus Babesia, which consists of ≈100 species (1)(2)(3)(4). Human disease in North America is primarily attributed to Babesia microti, and clinical features range from asymptomatic infection to severe disease or death (1)(2)(3)(4)(5)(6). A small number of cases of locally acquired human B. microti infections in Central and Western Canada have been described (3)(4)(5)(6). We report a confirmed case of babesiosis from Atlantic Canada in an area where Lyme disease and anaplasmosis are endemic (7)(8)(9). All clinical features and laboratory findings were consistent with babesiosis (4).
A 58-year-old immunocompetent man sought care at a hospital in southwest Nova Scotia, Canada, in July 2021 for a 3-day history of nonspecific symptoms (headache, photophobia, fatigue, general weakness, and fever up to 40°C). The patient's most recent travel was to Maine (USA) 25 years prior. He did not recall any recent tick bites; however, he had been treated for Lyme disease 3 times since 2019.
At admission, laboratory results were unremarkable aside from elevated C-reactive protein (164 mg/L [reference range <8 mg/L]) and high lactate dehydrogenase (372 U/L [reference range 120-230 U/L]). Leukocyte counts were normal except for a new onset of thrombocytopenia (platelet count 73 × 10 9 /L). Wright-stained peripheral blood smears revealed intra-erythrocytic ring forms and extracellular merozoites (Figure). Parasitemia was estimated at 2.3%. Results of BinaxNow malaria testing was negative (Abbott Laboratories, https://www.globalpointofcare.abbott). B. microti-specific PCR performed on whole blood at the National Microbiology Laboratory (Winnipeg, Manitoba, Canada) was positive.
B. microti is primarily transmitted through feeding of infected nymphal and adult female ticks (1-3). In Atlantic Canada, the vector (Ixodes scapularis blacklegged ticks) and reservoir (the white-footed mouse Peromyscus leucopus) for B. microti are the same as those for Borrelia burgdorferi (7). Locally acquired B. microti infections are thought to be rare in Canada; previous cases were reported only recently from Central and Western Canada (3)(4)(5)(6), and only rare occurrences are described in previous surveillance in human, animal, and ticks (6,10). Climate change and other environmental factors are now known to influence the abundance, range, and activity of ticks and reservoirs, as well as the risks for human exposure to tickborne pathogens (1,10). As seen with the increasing spread of Ixodes ricinus ticks in Europe (1), a northward expansion of blacklegged ticks is occurring in the southern parts of central and western Canada and in the Atlantic provinces, along with a concomitant rise in reported cases of Lyme disease (10). Compared with other provinces of Canada, Nova Scotia has the highest incidence of Lyme disease, increasing from 1.7 to 26.1 cases/100,000 population during 2009-2015 (7). Recently, increasing reports of ticks

RESEARCH LETTERS
In July 2021, a PCR-confirmed case of locally acquired Babesia microti infection was reported in Atlantic Canada. Clinical features were consistent with babesiosis and resolved after treatment. In a region where Lyme disease and anaplasmosis are endemic, the occurrence of babesiosis emphasizes the need to enhance surveillance of tickborne infections.
infected with Anaplasma phagocytophilum and cases of human granulocytic anaplasmosis also have been documented in Nova Scotia (8,9). This case of locally acquired B. microti infection adds another item to the menu of tickborne diseases in that Atlantic province. In absence of transovarial transmission in ticks with B. microti, expansion of the vector alone is unlikely to increase babesiosis cases unless sufficient amplification of the parasite is occurring in natural reservoirs. In northeast sections of North America, human infections caused by B. microti appear to be limited to the white-footed mouse, short-tailed shrew (Blarina spp.), and chipmunks (Tamia striatus) (1). Ongoing surveillance of tickborne disease in Atlantic Canada should include monitoring for B. microti in humans, ticks, and small mammals.
The discovery of B. microti infection in Atlantic Canada is important for multiple reasons. From a clinical perspective, physicians should be aware of the possibility of babesiosis occurring in the region, be able to recognize compatible symptoms, and be prepared to trigger proper investigations and implement therapeutic options when warranted. Because Lyme disease and anaplasmosis are already endemic in Nova Scotia, co-infections also should be considered if B. microti is detected; however, without evidence supporting the reciprocal conclusion, treatment of B. microti infection in cases of Lyme disease should only be considered if compatible with the clinical context (8,9). Ongoing surveillance, increased awareness, and education should be encouraged to better define and understand the changing epidemiology of tickborne diseases in Atlantic Canada. W ildlife viromes harbor potentially threatening zoonoses for humans that require increased effort in identification and surveillance (1). Rodents are considered main reservoirs of emerging zoonoses (2), and the large population fluctuations of reservoir species play a key role in modulating infection risk (3). Anthropogenic land-use changes, agricultural intensification, and irrigation also favor rodent invasions and risk for pathogen spillover (4). The common vole (Microtus arvalis) is a widespread rodent inhabiting intensified farming landscapes in northwestern Spain, where population numbers and pathogen prevalence lead to spillover of zoonotic bacteria such as Francisella tularensis and Bartonella spp. (5).
We report the prevalence of rodent-borne zoonotic viruses in Europe (i.e., hantavirus, arenavirus [lymphocytic choriomeningitis virus (LCMV)], and orthopoxvirus) (6) among the small mammals inhabiting farming landscapes. We also report the effect of natural fluctuations of common vole numbers on viral prevalence (phase dependence). Our study was conducted in intensively farmed landscapes, in the Tierra de Campos region of Castillay-León, northwestern Spain (7), where the small mammal population is mainly composed of 4 species: common vole, long-tailed field mouse (Apodemus sylvaticus), western Mediterranean mouse (Mus spretus), and greater white-toothed shrew (Crocidura russula) (7).
We live-trapped small mammals during March 2013-March 2019. We collected samples from blood, spleen, liver, and lungs by using standard protocols and stored them at -23°C until molecular analysis could be performed (Appendix, https://wwwnc. cdc.gov/EID/article/28/6/21-2508-App1.pdf). We owned all necessary licenses and permits for conducting this study.
We detected specific hantavirus, LCMV, and orthopoxvirus IgG in serum samples by using immunofluorescence assay. We used fluorescein isothiocyanate (FITC) anti-IgG as a secondary antibody and evaluated all slides under a fluorescence microscope. For molecular analysis, we isolated RNA from liver and lung tissues and DNA from a mix of liver and spleen. We performed single-step reverse transcription PCR (RT-PCR) for LCMV detection in the liver, nested reverse transcription PCR for hantavirus detection in lung samples, and conventional pan-poxvirus PCR method followed by an additional orthopoxvirus-specific PCR for orthopoxvirus detection in the mix samples. We used generalized linear models to test variations of prevalence between species and calculate prevalence in common voles according to host sex (male or female), trapping month (March, July, or November), and population density phase (increase, peak, or crash).
We screened 526 individual animals from 4 species for the presence of 3 viruses (Table; Appendix). We found evidence of hantavirus infection only in

RESEARCH LETTERS
We screened 526 wild small mammals for zoonotic viruses in northwest Spain and found hantavirus in common voles (Microtus arvalis) (1.5%) and high prevalence (48%) of orthopoxvirus among western Mediterranean mice (Mus spretus). We also detected arenavirus among small mammals. These findings suggest novel risks for viral transmission in the region.